Conservative treatment or surgery for shoulder impingement: systematic review and meta-analysis

DATA SOURCES: Cochrane Controlled Trials Register, MEDLINE, EMBASE, CINAHL and Science Citation Index databases were searched in March 2013 unrestricted by date or language. STUDY SELECTION: Controlled randomized (RCT) or quasi-randomized clinical trials comparing surgery and conservative treatment of shoulder impingement were included. DATA EXTRACTION: The methodological quality of each included trial was assessed according to the Cochrane Collaboration&#39;s domain-based evaluation framework. DATA SYNTHESIS: Of seven included RCTs, risk of systematic bias was considered to be low for two, high for four, and unclear for one RCT. The random-effect meta-analysis was conducted on four RCTs involving 347 subjects (173 surgically treated cases and 174 controls). There was no significant difference in changes in pain intensity between surgically and conservatively treated subjects (Hedges&#39;s g&thinsp;=&thinsp;0.01 in favor of conservative treatment, 95% CI -0.27 to 0.30). CONCLUSION: Based on the review of seven RCTs, the evidence on effectiveness of surgical or conservative treatment of shoulder impingement was found to be limited. There was, however, moderate evidence that surgical treatment is not more effective than active exercises on reducing pain intensity caused by shoulder impingement. Implications for Rehabilitation Based on the review of seven RCTs, the evidence on effectiveness of surgical or conservative treatment of shoulder impingement was found to be limited. There was moderate evidence that surgical treatment is not more effective than active exercises on reducing pain intensity caused by shoulder impingement. Because of surgery&#39;s higher costs and susceptibility for complications compared with costs and risks of conservative treatment, conservative treatment can be recommended as a first choice of treatment of shoulder impingement in first or second grade.</p

Increasing incidence of rotator cuff repairs—A nationwide registry study in Finland

Background Rotator cuff repair incidence rates have reportedly increased in the United States and England. Here we analyzed nationwide data relating to rotator cuff repairs recorded in the Finnish National Hospital Discharge Register (NHDR). Methods The NHDR was reviewed to identify adult patients who underwent rotator cuff repair between 1998 and 2011. Incidence rates per 10 5 person-years were calculated using the annual adult population size. Results During the 14-year time period, 50,646 rotator cuff repairs were performed on subjects aged 18 years or older. The incidence of rotator cuff repair showed an almost linear increase of 204 %, from 44 per 10 5 person-years in 1998 to 131 per 10 5 person-years in 2011. The most common concomitant procedure was acromioplasty, which was performed in approximately 40 % of rotator cuff repairs in 2011. Other common concomitant procedures included tenodesis (7 %) and tenotomy (6 %) of the long head of the biceps tendon, and resection of the acromioclavicular joint (3 %). Conclusions This nationwide analysis revealed a remarkable increase in the incidence of rotator cuff repair from 1998 to 2011 in Finland. This progress can be questioned, since there are not convincing data of the superiority of the operative treatment over non-operative management in all rotator cuff tears.BioMed Central open acces

Declining incidence of acromioplasty in Finland

Background and purpose — An increased incidence rate of acromioplasty has been reported; we analyzed data from the Finnish National Hospital Discharge Register. Patients and methods — During the 14-year study period (1998–2011), 68,877 acromioplasties without rotator cuff repair were performed on subjects aged 18 years or older. Results — The incidence of acromioplasty increased by 117% from 75 to 163 per 105 person years between 1998 and 2007. The highest incidence was observed in 2007, after which the incidence rate decreased by 20% to 131 per 105 person years in 2011. The incidence declined even more at non-profit public hospitals from 2007 to 2011. In contrast, it continued to rise at profit-based private orthopedic clinics. Interpretation — We propose that this change in clinical practice is due to accumulating high-quality scientific evidence that shows no difference in outcome between acromioplasty and nonsurgical interventions for rotator cuff disease with subacromial impingement syndrome. However, the exact cause of the declining incidence cannot be defined based solely on a registry study. Interestingly, this change was not observed at private clinics, where the number of operations increased steadily from 2007 to 2011

Surgery or conservative treatment for rotator cuff tear: a meta-analysis

Purpose: Comparative evidence on treating rotator cuff tear is inconclusive. The objective of this review was to evaluate the evidence on effectiveness of tendon repair in reducing pain and improving function of the shoulder when compared with conservative treatment of symptomatic rotator cuff tear.Method: Search on CENTRAL, MEDLINE, EMBASE, CINAHL, Web of Science and Pedro databases. Randomised controlled trials (RCT) comparing surgery and conservative treatment of rotator cuff tear. Study selection and extraction based on the Cochrane Handbook for Systematic reviews of Interventions. Random effects meta-analysis.Results: Three identified RCTs involved 252 participants (123 cases and 129 controls). The risk of bias was considered low for all three RCTs. For Constant score, statistically insignificant effect size was 5.6 (95% CI −0.41 to 11.62) points in 1-year follow up favouring surgery and below the level of minimal clinically important difference. The respective difference in pain reduction was −0.93 (95% CI −1.65 to −0.21) cm on a 0–10 pain visual analogue scale favouring surgery. The difference was statistically significant (p = 0.012) in 1-year follow up but below the level of minimal clinically important difference.Conclusion: There is limited evidence that surgery is not more effective in treating rotator cuff tear than conservative treatment alone. Thus, a conservative approach is advocated as the initial treatment modality.</p

Increasing incidence of primary shoulder arthroplasty in Finland - a nationwide registry study

Background: The incidence of shoulder arthroplasties is reportedly increasing and the types of arthroplasty are changing. The purpose of this study was to investigate the incidence of primary shoulder arthroplasty in Finland.Methods: We analyzed nationwide data from the Finnish Arthroplasty Register (FAR) and the Finnish National Hospital Discharge Register (NHDR) during time period 2004-2015. The primary outcome variable was the incidence of shoulder arthroplasty per 100,000 person-years stratified by age, sex and year of surgery. The secondary outcome variables were surgical indication, arthroplasty type and prosthesis model.Results: The number of primary shoulder arthroplasties was 7504 (women = 4878, men = 2625). The rate of operations increased from 6 to 15 per 100,000 person-years among men, and 11 to 26 per 100,000 person-years among women. The indication for arthroplasty was osteoarthritis in 56%, acute fracture in 21%, inflammatory arthritis in 13%, and rotator cuff arthropathy in 4% of the cases. Hemiarthroplasties accounted for 66%, total shoulder arthroplasties 8%, and reverse shoulder arthroplasties 12% of the cases, 14% of the cases was missing. During the 12-year study period the incidence of hemiarthroplasties decreased by 23% and the number of total shoulder and reverse shoulder arthroplasty increased by 500 and 4500%, respectively.Conclusions: The incidence of primary shoulder arthroplasty has increased by 160% during the study period in Finland. The incidence of hemiarthroplasties decreased while total and reverse shoulder arthroplasties increased

Operative versus conservative treatment of small, nontraumatic supraspinatus tears in patients older than 55 years: over 5-year follow-up of a randomized controlled trial

BackgroundNontraumatic rotator cuff tear is a common shoulder problem that can be treated either conservatively or operatively. In the previous publications of the 1- and 2-year results of this trial, we found no significant between-group clinical differences. The aim of this study was to investigate the differences in mid-term clinical and radiologic outcomes in patients older than 55 years.Materials and methodsOne hundred eighty shoulders with symptomatic, nontraumatic supraspinatus tears were randomly assigned to 1 of the 3 cumulatively designed treatment groups: physiotherapy (group 1); acromioplasty and physiotherapy (group 2); and rotator cuff repair, acromioplasty, and physiotherapy (group 3). The change in the Constant score was the primary outcome measure. The secondary outcome measures were the change in the visual analog scale score for pain and patient satisfaction. Radiologic analysis included evaluation of glenohumeral osteoarthritis (OA) and rotator cuff tear arthropathy (CTA).ResultsA total of 150 shoulders (mean age, 71 years) were available for analysis after a mean follow-up period of 6.2 years. The mean sagittal tear size of the supraspinatus tendon tear at baseline was 10 mm in all groups (P = .33). During follow-up, 8 shoulders in group 1 and 2 shoulders in group 2 crossed over to rotator cuff repair. The mean baseline Constant score was 57.1, 58.2, and 58.7 in groups 1, 2, and 3, respectively (P = .85). There were no significant differences (P = .84) in the mean change in the Constant score: 18.5 in group 1, 17.9 in group 2, and 20.0 in group 3. There were no statistically significant differences in the change in the visual analog scale pain score (P = .74) and patient satisfaction (P = .83). At follow-up, there were no statistically significant differences in the mean progression of glenohumeral OA (P = .538) or CTA (P = .485) among the groups. However, the mean progression of glenohumeral OA from baseline to follow-up was statistically significant in the trial population (P = .0045).ConclusionsOn the basis of this study, operative treatment is no better than conservative treatment regarding small, nontraumatic, single-tendon supraspinatus tears in patients older than 55 years. Operative treatment does not protect against degeneration of the glenohumeral joint or CTA. Conservative treatment is a reasonable option for the primary initial treatment of these tears.Level of evidenceLevel IIRandomized Controlled TrialTreatment StudyKeywordsRotator cuff tearconservative treatmentrotator cuff repairConstant scoreVAS pain scorepatient satisfactionradiographic analysisrandomized controlled trial </div

Mortality and subsequent fractures of patients with olecranon fractures compared to other upper extremity osteoporotic fractures

Background: The incidence rate of olecranon fractures is highest in the elderly population. The aim of this study was to determine whether patients with olecranon fractures have similar demographic and risk characteristics compared to patients with osteoporotic upper extremity fractures.Methods: A retrospective data analysis was performed with diagnoses for olecranon fracture, distal radius fracture and proximal humerus fracture between 2014 and 2016.Results: A total of 157 olecranon, 1022 distal radius and 451 proximal humerus fractures were identified. The risk of mortality after olecranon and distal radius fractures was comparable but statistically significantly higher after proximal humerus fractures (HR 1.97, 95% CI 1.19–3.27). The risk of subsequent osteoporotic fractures after an olecranon fracture was 10% at 1 year and 14% at 5 years and the risks did not differ statistically after a proximal humerus fracture, 6% and 11% (HR 0.65, 95% CI 0.40–1.06). After a distal radius fracture, the risks were statistically significantly lower: 2% and 5% (HR 0.35, 95% CI 0.22–0.56).Discussion: Patients with olecranon fractures have essentially similar demographic characteristics compared to patients with distal radius fractures, but the probability for a subsequent fracture is significantly higher and more comparable to patients with proximal humerus fractures.</p

Radiographic geometry and clinical glenohumeral range of motion after reverse shoulder athroplasty, a retrospective cohort study

BackgroundThe range of motion (ROM) in reverse shoulder arthroplasty (RSA), is mechanically limited by the surrounding bony obstacles especially in abduction and rotation planes. However, the clinical effect of implant positioning, prosthesis design, and individual differences in bone morphology, on ROM is obscure. The aim of this study was to investigate the correlation between radiographic geometry and clinical glenohumeral (GH) ROM after RSA.MethodsRSA patients operated at Turku University Hospital during 2007–2013 were called for radiological and clinical follow-up. Pre- and postoperative true anteroposterior radiographs were obtained and the positioning of the center of rotation (COR) in relation to the surrounding bony structures was measured. Active and passive shoulder and GH abduction, flexion, internal and external rotation ROM were measured with goniometer. The Constant score (CS) and pain visual analogue scale (VAS) were recorded. The correlation between the radiographically measured parameters and the active and passive ROM and clinical outcome was statistically analyzed.Results91 shoulders were available for analyses with a mean follow-up of 38.7 months ± SD 20 (range 12–83) months. 77% of the patients were female, the mean age was 73 (SD 9) years. The mean angle between the line of supraspinatus fossa, and the line between COR and lateral edge of the acromion (α-angle) was 127° (SD 14) and the mean angle between the lines from lateral edge of the acromion to COR, and from there to the superior edge of the greater tubercle (β-angle) was 54° (SD 11). The mean active shoulder flexion at follow-up was 118° (SD 26), abduction 104° (SD 32), external rotation 41° (SD 22), internal rotation 77° (SD 21). The mean passive GH flexion was 80° (SD 19), abduction 67° (SD 15), external rotation 31° (SD 16) and internal rotation 34° (SD 14). The mean Constant score at follow-up was 53 (SD 18) and pain VAS 2 (SD 3). The positioning of the radiographically measured COR did not statistically significantly correlate with the ROM or clinical outcome scores.ConclusionsPostoperative radiographically measured two-dimensional geometry and positioning of the COR does not significantly correlate with the glenohumeral range of motion or clinical results after RSA.</p

Scandinavian Olecranon Research in the Elderly (SCORE) : protocol for a non- inferiority, randomised, controlled, multicentre trial comparing operative and conservative treatment of olecranon fractures in the elderly

Introduction The incidence of olecranon fractures is growing in the elderly population. The traditional operative approach is giving way among the elderly to conservative treatment, which seems to provide a comparable functional outcome with a lower complication burden. However, there is still a lack of reliable evidence to support this shift. The objective of this trial is to investigate whether conservative treatment of displaced olecranon fractures in patients aged 75 or older yields comparable results to those of operative treatment in terms of pain and daily function. Methods and analysis Scandinavian Olecranon Research in the Elderly (SCORE) is a randomised, controlled, multicentre, non-inferiority trial. Eligible patients will be randomised to either conservative or operative treatment. The sample size will be 68 patients and allocation done at a 1:1 ratio (34 patients per group). The randomisation is stratified according to the participating hospital and patient's sex. Both groups will receive the same postoperative physiotherapy and pain management. The primary outcome is Disabilities of the Arm, Shoulder and Hand at 1-year follow-up. Secondary outcomes are pain and satisfaction measured on visual analogue scales, Patient Reported Elbow Evaluation, range of motion of the elbow and extension strength of the elbow compared with the unaffected arm. Radiographs will be taken at each follow-up. Primary analysis of the results will be conducted on an intention-to-treat basis. Ethics and dissemination The study protocol for this clinical trial has been approved by the Ethics Committee of the Hospital District of Southwest Finland and will be submitted for approval to the Regional Ethics Committees in Linkoping, Sweden and Copenhagen, Denmark. Every recruiting centre will apply local research approvals. The results of this study will be submitted for publication in peer-reviewed journals.Peer reviewe